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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOIE, OFFICE USE: i,,"-­1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San JoZCENSUS <br /> in Local Health District. <br /> JOB ADDRESS/LOCATION P=�}} / ,,,,� ,Q <br /> i��GG{� �i'�� TRACT <br /> Owner's Name Phone R <br /> 1 <br /> Addressd City zeae__O� <br /> Contxact .r's Name d License 167 hone - / <br /> i <br /> TYPE OF MORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION -LD7 PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC'WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ►f <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �` q <br /> Irrigation Gravel Pack Depth of Grout Seal ! `U <br /> Cathodic Protection Rotary Type of Grout � . <br /> Disposal Other Other Information ' <br /> Geophysical_ c Surface Seal Insoalled By: <br /> PUMP INSTALLATION: Contractor -r <br /> -t Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ .� Approximate Depth <br /> Describe 'Material and Procedure <br /> I hereby agree to comply with all laws. and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the hest of- my knowledge and belief. I WILL C OR A GROUT INSPECTION <br /> PRIOR TO G OUTING FINAL INSPECTION. <br /> SIGNED TITLE -49 <br /> MEW- POT PLAN 'ON RE FRSE SIMI , -, <br /> FOR PARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II IN INSPEG ON <br /> / <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 3/76 2M. <br />